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A Case of a Suicide Attempt by Taxus Baccata Leaves Poisoning

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A Case of a Suicide Attempt by Taxus Baccata Leaves Poisoning ica Clin l T of ox l i a c n o r l o u g o y J ISSN: 2161-0495 Journal of Clinical Toxicology Case Report A Case of a Suicide Attempt by Taxus baccata Leaves Poisoning Beñat de Alba Iriarte1*, Eva Lorea Gil Rodríguez1, Edurne Bereciartua Urbieta1, María Elena Redín Sarasola1, Txoan Ormazabal Zabala2, Mikel Díez Bengoechea2, María Asunción Vives Almandoz1, Adolfo Garrido Chércoles1, Oscar Quintela Jorge3 1Osakidetza Basque Health Service, Donostia University Hospital, Clinical Biochemistry Laboratory, Donostia-San Sebastián, Spain; 2Osakidetza Basque Health Service, Donostia University Hospital, Intensive Care Unit, Donostia-San Sebastián, Spain; 3National Institute of Toxicology and Forensic Sciences, Department of Madrid, Chemistry Service, Las Rozas de Madrid, Spain ABSTRACT Taxus baccata is one of the most poisonous trees in the world. It contains taxanes and toxic alkaloids: the most dangerous one is the taxine. It is a fairly common plant in our environment and could be extremely dangerous; however, yew poisoning is quite rare. Cases may occur by voluntary or accidental ingestion. Therefore, the rapid orientation and diagnosis of suspected episode are important, in order to treat it quickly. There are no specific clinical or analytical alterations in this intoxication and it is very difficult to determine in each case the evolution of the episode. Patients who ingest a lethal dose frequently die due to cardiac arrest, in spite of resuscitation efforts. At present, no specific therapy exists. Therapeutic procedures reported in the literature are only referred to in published case reports, so there is insufficient evidence to recommend any treatment in yew poisoning. In our case report, we describe poisoning by ingestion of Taxus baccata leaves in a suicide attempt, its clinical evolution and its management and we do a brief review of the literature about yew poisoning. Keywords: 3,5-dimethoxyphenol; Cardiotoxicity; Poisoning; Taxine; Taxus baccata; Yew ABBREVIATIONS: CASE PRESENTATION ECG: Electrocardiogram; GC: Gas Chromatography; MS: Mass 48-year-old man was transferred by ambulance to the emergency Spectrometry department of the hospital, with no symptoms, 2 hours after autolytic attempt by abundant yew leaves ingestion. He was INTRODUCTION aware of the arrival of the ambulance and he said that he was Taxus baccata (Common yew, English yew, or European yew), cutting yew leaves and ingesting them, although he could not native to western, central and southern Europe, is one of the specify the exact amount. The physical examination was normal and the analysis only presented respiratory alkalosis, mild most poisonous trees in the world. It contains taxanes (from 3 which antineoplastic drugs, such as paclitaxel, are obtained) and leukocytosis (13.75 × 10 /µL (3.8-10)) and increased lactate (4.66 toxic alkaloids. The most dangerous one is the taxine, a dose- mmol/L (<2)). dependent sodium and calcium channel antagonist. While in emergency room stay he suffered from abrupt reduced It is a fairly common plant in our environment and could be consciousness and ventricular fibrillation that had required extremely dangerous; however, yew poisoning is quite rare. The electrical cardioversion, 200 joules twice. Subsequently, he whole tree is toxic, except for the aril of its berries. Cases may presented aberrated rhythm with wide QRS and ventricular occur by voluntary or accidental ingestion. Therefore, the rapid tachycardia. Amiodarone (IV 300 mg) was administered and orientation and diagnosis of suspected episode are important, in orotracheal intubation and mechanic ventilation were order to treat it quickly. performed. Therefore, he entered the intensive care unit. The Correspondence to: Beñat de Alba Iriarte, Osakidetza Basque Health Service, Donostia University Hospital, Clinical Biochemistry Laboratory, Donostia-San Sebastián, Spain, E-mail: [email protected] Received: May 26, 2020; Accepted: June 09, 2020; Published: June 16, 2020 Citation: Iriarte BA, Gil EL, Bereciartua E, Redín ME, Ormazabal T, Díez M, et al. (2020) A Case of a Suicide Attempt by Taxus baccata Leaves Poisoning. J ClinToxicol. 10:443. DOI: 10.35248/2161-0495.20.10.443 Copyright: © 2020 Iriarte BA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. J Clin Toxicol, Vol.10 Iss.4 No:1000443 1 Iriarte BA, et al. results of a second analysis were leukocytosis (20.96 × 103/µL troponin T (19.3 ng/L (0-14)) and creatine kinase (237 U/L (3.8-10)) and increased lactate 2.89 mmol/L (<2), high-sensitivity (0-189)). Rest of the analysis were normal (Table 1). Table 1: Analysis results. Reference Results values Parameters (Units) 18 March 18 March 18 March 19 March 20 March 21 March 17:45 19:35 21:25 8:15 8:15 8:25 Sodium (mEq/L) 137 136 138 140 135 142 [135-145] Chlorine (mEq/L) 96 98 97 103 104 107 [93-110] Potasium (mEq/L) 3.77 3.68 3.72 4.62 3.99 3.83 [3.3-5.1] Glucose (mg/dL) 109 186 263 124 117 94 [70-110] Bilirubin (mg/dL) - 1.19 - 1.67 1.71 1.29 [0-1.1] Creatinine (mg/dL) 0.98 0.95 1.02 1.01 0.7 0.67 [0.70-1.20] Total proteins (g/dL) 7.32 5.9 5.93 5.91 - - [6.6-8.7] Calcium (mg/dL) 10.1 8.1 8.7 8.5 - - [8.6-10.2] Lactate (mg/dL) 4.66 2.89 2.78 1.55 1.67 - [<2] High-sensitivity troponin T (ng/L) - 19.3 110 99.9 - - [0-14] NT-proBNP (pg/mL) - 96 217 1222 - - [0-300] Creatine kinase (U/L) - 237 427 - - - [0-189] C-reactive protein (mg/L) - 1.9 - 24.6 96.7 56.4 [0-5] Procalcitonin (ng/mL) - - - 0.83 0.56 0.36 [<0.5] Red blood cells (*106/µL) 5.17 4.83 5.15 5.08 4.11 4.14 [4.3-5.6] Hemoglobin (g/dL) 15.5 14.7 15.8 15.4 12.7 12.5 [13-17] White blood cells (*103/µL) 13.75 20.96 26.06 19.33 13.84 10.54 [3.8-10] Platelets (*103/µL) 235 204 229 216 160 133 [140-400] Prothrombin time (%) - 86 - 83 75 90 [70-140] APTT (sec) - 26.4 - 29.6 33.8 31.4 [24-36] pH 7.63 7.36 7.36 7.47 7.43 - [7.35-7.45] pO2 (mmHg) 112 193 380 188 102 - [83-108] pCO2 (mmHg) 15 32 37 32 36 - [35-48] Bicarbonate (mmol/L) 15.8 18.1 20.9 23.3 23.9 - [21-28] O2 saturation (%) 98.8 99.7 100.2 99.8 98.8 - [95-99] Since admission, he had tendency to bradycardia (less than 50 beats/min). Nasogastric tube was placed and activated charcoal beats/min) alternating with wide QRS tachycardia (up to 110 and Mg sulfate (IV 1 g) were administered. Treatment with J Clin Toxicol, Vol.10 Iss.4 No:1000443 2 Iriarte BA, et al. vasopressor support with norepinephrine and inotropic support with dopamine was also initiated, and calcium gluconate (IV 200 mg) was given for the purpose of myocardial membrane stabilization. He had some episodes of pulseless ventricular tachycardia that required several attempts of electrical cardioversion, reversing the episodes to chaotic rhythms with wide QRS and tendency to bradycardia. Therefore, an external pacemaker was placed to recover the cardiac frequency and the blood pressure. Doctors called toxicology department that referred there is no antidote for this poisoning and recommended continuing with activated charcoal, forcing diuresis without alkalizing the urine and treating with vasoactive support. After 24 hours, he achieved progressive clinical and hemodynamic stabilization. The ECG, after this stabilization, showed signs compatible with Brugada Syndrome type I in V1-V2. Apparently, yew toxin interacts in the same sites (sodium channels) as in people who genetically have this syndrome. With Glasgow 15, the extubation proceeded without problems and the pacemaker was removed, after confirming by echocardiogram that he had no cardiac abnormalities. In analysis, leukocytes and cardiac enzymes were altered with good evolution. Given the normalization of the ECG and the absence of arrhythmic events in the next 72 hours, the episode was interpreted as secondary to the toxin of yew, so it was not considered convenient to adopt other measures. He fully recovered in a week. The final diagnosis was confirmed by the detection of 3,5- dimethoxyphenol, by GC/MS. Samples (EDTA blood and Figure 1: Taxus baccata in Usurbil, Gipuzkoa (Basque Country). heparin plasma) were analyzed by the Spanish National Institute of Toxicology and Forensic Sciences, 7 months after their obtention and preservation at 2-8°C. 3,5-dimethoxyphenol was The yew tree has been known since antiquity for its toxicity. It detected in both samples. was a sacred tree for the Celts. In ancient times, it was a desired species, particularly for its high quality wood, and was studied DISCUSSION both for its medicinal and poisonous properties. It was known Yew (Taxus spp.) is a coniferous tree of the Taxaceae family, as the “tree of death” by the Greeks and Romans and among the typical of mountainous areas with cool and humid ancient Galician, Asturian, Cantabrian and Vasconian environments. It contains taxanes and toxic alkaloids (such as populations of the Iberian Peninsula the practice of suicide with taxine). There are many species and one of them is Taxus baccata yew poison was widespread. It was part of some of their rituals, [1]. probably due to the extraordinary longevity of the plant, which makes it seem immortal.
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